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arly complications of operatively treatedroximal humeral fractures

dam M. Smith, MD,a Rodrigo M. Mardones, MD,b John W. Sperling, MD,c and Robert H. Cofield, MD,c

exington, KY, Santiago, Chile, and Rochester, MN

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inimal information exists regarding early complica-ions after operatively treated proximal humeral frac-ures. Of the 82 shoulders that had osteosynthesis, 42ad a (nonmedical) complication, with 21 requiringurther surgery. Of 42 shoulders with complications,2 were related to incomplete reduction, 16 had lossf anatomic fracture fixation, 9 had delayed healing,had an infection, 1 had rotator cuff failure, and 1

ad loose bodies. Fixed-angle plates had lower ratesf initial malpositioning and resultant malunion. Of the2 shoulders requiring hemiarthroplasty, 14 had anarly complication. Of these, 7 had complications re-ating to implant insertion or tuberosity malreduction athe index operation and 7 had problems with tuberos-ty healing. The rate of complications after operativereatment of proximal humeral fractures is high. Allfforts at fracture fragment fixation with osteosynthesisnd hemiarthroplasty should be directed at obtainingnatomic fracture fixation that resists displacement. (Jhoulder Elbow Surg 2007;16:14-24.)

perative management of fractures of the proximalumerus remains controversial, with results that areften disappointing. The most widely used classifica-

ion of proximal fractures is comprehensive and com-lex with reports of low to midrange interobservernd intraobserver reliability.5,10,26,27,29,30,36–38 Fur-

hermore, the results of operative treatment for dis-laced fractures have been mixed, with some authorsemonstrating that patients treated operatively fair noetter than those treated nonoperatively.12,21,43

Proximal humeral fracture management is demand-ng. Anatomic reconstruction can be difficult, and loss

rom the aKentucky Sports Medicine Clinic, Lexington; bDepart-mento de Ortopedia y Traumatología, Pontificia UniversidadCatólica de Chile, Santiago; and cDepartment of OrthopedicSurgery, Mayo Clinic and Mayo Foundation, Rochester.

eprint requests: John W. Sperling, MD, Department of OrthopedicSurgery, Mayo Clinic and Mayo Foundation, 200 First StreetSW, Rochester, MN 55905 (E-mail: sperling.john@mayo.edu).opyright © 2007 by Journal of Shoulder and Elbow SurgeryBoard of Trustees.

058-2746/2007/$32.00

3oi:10.1016/j.jse.2006.05.008

4

f fixation as a result of osteoporotic bone may leado fracture displacement and malunion.8,12 Youngeratients with satisfactory bone quality may have high-nergy injuries with associated trauma to other bodyegions and surrounding soft-tissue trauma, includingotator cuff tearing, and neurovascular injury can besource of future disability regardless of the fracture

reatment.3,6,11,22 Hemiarthroplasty, an attractive op-ion in patients with multiple displaced fragments andsteoporotic bone, has been associated with limitedhoulder motion, tuberosity resorption, and glenohu-eral instability, which are difficult complications to

alvage.8,14,28,32,34,40

Although several authors have examined the out-omes of operatively treated proximal humeral frac-ures, there is no report focusing on complications inatients undergoing operative treatment of proximalumeral fractures. Therefore, the purpose of this studyas to review the complications of operatively treatedroximal humeral fractures at our institution (Mayolinic, Rochester, MN) to determine the rates of earlyomplications and the potentially avoidable factorshat led to their occurrence. We hypothesize that theate of early complications in patients undergoingperative treatment is higher than previously re-orted.

ETHODS

A computer-assisted search of the surgical database atur institution was performed to identify patients who hadperative fixation or arthroplasty for fracture of the proxi-al humerus from January 1995 to December 2002. Only

keletally mature patients from a 60-mile radius (regionalervice area) with acute fractures (�3 weeks from injury)ere included in the study to eliminate selection problems

rom our institution’s referral pattern, which frequently dealsith unusual or highly complex injuries. Approval for this

tudy was obtained from the Institutional Review Board.All medical records including associated surgical proce-

ures and available imaging studies were reviewed toxamine the type and frequency of complications encoun-ered. We identified 138 shoulders that met these criteria (2atients had bilateral fractures), of which 22 shoulders in2 patients were eliminated because no radiographs werevailable for examination. This left 116 shoulders for re-iew. In addition, 12 shoulders in 12 patients had less than

months of follow-up, of whom 2 had died, one 7 days

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J Shoulder Elbow Surg Smith et al 15Volume 16, Number 1

fter the initial procedure and one at 11 weeks. Therefore,04 shoulders in 102 patients were reviewed in detail forarly complications of operatively treated proximal humeralractures; 22 shoulders in 22 patients underwent hemiar-hroplasty, and 82 shoulders in 80 patients underwenturgical fixation.

In the 82 shoulders undergoing operative fracture fixa-ion, the median follow-up was 12 months (range, 3 monthso 7 years). The median age was 61 years (range, 17-96ears). Of these 82 shoulders, 19 had follow-up for 3 to 6onths and 63 had follow-up for 6 months or greater. Thereere 52 female and 28 male patients (2 female patientsad bilateral injuries). The mechanisms of injury in the 80atients included a fall from a standing position (46), a fallrom a height or stairs (16), a motor vehicle accident (12),nd a motorcycle/all-terrain vehicle crash (6). The median

ength of hospitalization was 4 days (range, 1-39 days).In the 22 shoulders undergoing hemiarthroplasty, the

edian follow-up was 2.1 years (range, 3 months to 5ears). The median age was 71 years (range, 29-87ears). Of the 22 shoulders, 3 had follow-up from 3 to 6onths and 19 had follow-up for 6 months or greater. Thereere 6 men and 16 women. The mechanisms of injury

ncluded a fall from a standing position (19), a fall from aeight or stairs (2), and a motor vehicle accident (1). Theean length of hospitalization was 4.5 days (range, 2-21ays).

Of the 104 shoulders, 42 (40%) had at least 1 associ-ted injury and 14 (14%) had 2 or more associated inju-ies. Of the shoulders, 12 had an associated rotator cuffear (7 of which were noted in the 22 shoulders undergoingemiarthroplasty). There was an associated injury to thepper limb girdle in 25 shoulders, and 12 had a lowerxtremity injury (including 6 with femur or hip fractures). Ofhe patients, 5 had chest or abdomen injuries, 6 had injuryo the axial skeleton (pelvis or spine), and 4 had facial oread trauma.

adiograph assessmentStandard radiographs included an anteroposterior view

f the proximal humerus in internal and external rotation,ateral scapular view, and axillary view. All fractures werelassified by the system described by Neer.26 Injury radio-raphs of the affected shoulder were examined and classi-ed by 4 orthopaedic surgeons (blinded to the operatingurgeon’s assessment) with specialty training in surgery ofhe shoulder, and a consensus was reached for fractureype. There were 8 shoulders in which the available injuryadiographs were inadequate to classify the fractures accu-ately. The fracture type was also recorded from the medicalecord based on the operating surgeon’s preoperative andntraoperative assessment of the fracture.

The operating surgeon reported 41 two-part, 39 three-art, and 23 four-part fractures, as well as 1 head-splittingracture. Consensus review by the authors demonstrated 49wo-part, 28 three-part, 13 four-part, 2 head-splitting, and 3ondisplaced fractures. Of the 2-part fractures, 41 involvedhe surgical neck and 9 were isolated greater tuberosityractures, of which 3 had associated anterior dislocations.f the 3-part fractures, 26 involved the humeral neck andreater tuberosity, of which 8 had associated dislocation (4

nterior and 4 posterior), and 3 involved the humeral neck c

nd lesser tuberosity. There were 13 four-part fractures, ofhich 3 had anterior dislocations.

efining complicationsAll patients (82 shoulders with osteosynthesis and 22

atients with hemiarthroplasty) were assessed for earlyomplications. This included medical and surgical compli-ations, which were defined as occurring from the time ofnjury and initial hospitalization up to 3 months postopera-ively. Surgical complications included events occurringntraoperatively or technical problems directly related to themplant placement or final fracture reduction. Radiographsere assessed from the initial postoperative radiographs

or quality of fragment reduction in the anteroposterior, 60°osterior oblique, and axillary views. A malreduction wasefined as a nonanatomic reduction of any fracture frag-ent (�1 cm of displacement or residual angulation of20° from a defined 135° head-shaft angle).1,2,17,18,41,42

All patients were followed up until healing had occurred orntil 6 months (which defined a delay in healing). The healingtatus of the fractures was determined by the following param-ters. A fracture was healed when there was both clinicaldefined by the clinical record) and radiographic evidence ofnion. Clinical union was defined as a painless fracture siten examination. Radiographic union was defined by bridg-ng callus or (with rigid fixation) direct bone healing be-ween fracture fragments on at least 2 orthogonal radio-raphic views.12 Delayed healing was defined as lack ofomplete fracture healing at a minimum of 6 months. Mal-nion was defined by nonanatomic healing of the humeralragments with at least 20° of angulation relative to theeck-shaft angle defined as 135°.1,2,17,18,41,42

Radiographs were examined for changes in fracturexation over time, such as implant breakage or change inosition, as well as fracture fragment displacement (greater

uberosity, lesser tuberosity, and humeral head). Displace-ent of greater than 1 cm and the direction of displacement

anterior, posterior, medial, lateral, inferior, varus, valgus)or the displaced fracture fragments were determined. Ra-iographs were also assessed for tuberosity resorption,

mplant-related problems, humeral head subluxation, andnfection. The humeral head was examined to determine theirection and amount of subluxation, which was expresseds a percentage of the width of the humeral head relative to

he center of the glenoid.1,2

perative dataOf the 104 shoulders, 16 had an initial trial of nonop-

rative treatment that required operative intervention be-ause of fracture displacement or an unstable reduction. Inhe remaining shoulders, a decision to perform operativentervention was made on the day of presentation. Theedian time to operative intervention for all fractures

reated was 4 days (range, day of injury to 3 weeks).In this retrospective review, the type of surgical proce-

ure chosen was based solely on surgeon preference afterssessment of the injury pattern. Cases were distributed tourgeons based on subspecialty interest, surgeon availabil-ty, and the urgency status of the case. Operations wereerformed by 15 different surgeons, all of whom are board-

ertified orthopaedic surgeons at our institution with ongo-

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16 Smith et al J Shoulder Elbow SurgJanuary/February 2007

ng participation in the care of trauma patients. Four ofhese surgeons have practices largely or primarily consist-ng of shoulder surgery. Of the hemiarthroplasties, 15 wereerformed by shoulder surgeons and 7 by nonshoulderurgeons. Of the shoulders undergoing osteosynthesis,houlder surgeons performed 57 and nonshoulder surgeonserformed 25.

Of the 82 shoulders undergoing operative fixation, 1721%) underwent closed reduction and percutaneous fixa-ion with terminally threaded wires or an intramedullarytaple device (Smith & Nephew, Memphis, TN),25 2227%) had fixation with a fixed-angle blade plate or lockinglate (Synthes, Paoli, PA), 18 (22%) had fixation with an

ntramedullary device with a tension band, 18 (22%) hadxation with a non–fixed-angle construct, 4 (4%) had fixa-ion with screws or a tension band (or both), and 3 (3%) hadxation with a locking intramedullary nail. Ten patientsnderwent allograft bone grafting at the index procedure.wenty-two shoulders underwent cemented hemiarthro-lasty via the deltopectoral approach. Tuberosities wereeconstructed in a similar manner in all cases with suturexation of the fractured tuberosities to each other, theumeral shaft, and the implant stem. Bone graft from theumeral head remnants was applied adjacent to the hu-eral stem under the repaired tuberosities in all cases.

ehabilitationPostoperatively, patients’ shoulders were placed in a

houlder immobilizer with the arm at the side or with anbduction orthosis based on surgeon preference. Passiveange-of-motion exercises for elevation and external rota-ion were started at the discretion of the operating surgeonnd were continued until initial radiographic healing wasocumented. An active assisted motion program was ad-anced when the fracture had stabilized. Stretching andtrengthening with an elastic strap were started after frac-ure healing.

tatistical analysisThe association between the 4 most common types of

steosynthesis complications was assessed by use of theisher exact test. For the complications of malpositioningnd malunion, although the overall test was significant,airwise comparisons were also performed by use of theisher exact test. The P values reported are unadjusted forhe multiple comparisons. The association between compli-ations and level of expertise with shoulder surgery (ie,houlder surgeon vs nonshoulder surgeon) was also as-essed with the Fisher exact test. An � level less than orqual .05 was considered as statistically significant.

ESULTSedical complications

Major medical complications occurred in 6 of 102atients within 3 months of the injury. There were 4atients who had a pulmonary embolus and 2 whoad a myocardial infarction during the initial hospi-alization and survived for fracture care follow-up.he median number of hospital days to discharge was

0 (range, 6-18 days). 5

omplications in osteosynthesis group

Of the 82 shoulders undergoing osteosynthesis ofhe proximal humerus, 42 (51%) had an early com-lication, with 21 shoulders (26%) undergoing reop-ration. Of the 82 fractures, 65 (79%) healed withoutelay or further intervention at less than 6 monthshereas 17 (21%) had delayed fracture healing at

he 6-month interval.Surgical complications (events occurring during

he index procedure not including medical complica-ions) occurred in 12 of 82 shoulders (15%) undergo-ng osteosynthesis. All 12 shoulders had an incom-lete reduction of the proximal humeral fragments onostoperative radiographs (Figure 1) and were asso-iated with a complex constellation of complications,ncluding fragment displacement and malunion oronunion (Figure 2). Of these 12, malreduction wasssociated with malunion in 8 (1 of which had aostoperative brachial plexopathy and 2 had furtherisplacement of the fracture), nonunion in 3 (2 ofhich had further fracture displacement), and tuber-sity resorption in 1.

In the remaining shoulders that had acceptablenitial fracture reduction, 13 had loss of fixation withracture displacement, resulting in malunion in 10nd nonunion is 3. Three patients had implant migra-

ion (screw backout or intramedullary rod loosening)ithout substantial change in fracture position. Thereere 9 patients who had delayed healing with novidence of fracture malreduction or displacement.f these, 8 healed 6 months after the initial injury (3

equired revision fixation with bone grafting, with 1aving resultant nonunion).

Three patients had a postoperative infection. Oneas superficial, was treated with oral antibiotics only,nd healed without further intervention. Two othersere treated for acute deep infection with irrigationnd debridement with retention of hardware and

ntravenous antibiotics. Of these 2, 1 healed in 3onths and 1 went on to have nonunion requiring

racture site and bone grafting with resultant non-nion.

Other early complications included 1 patient with3-part fracture, with blade plate fixation, in whom

arrowing of the acromiohumeral distance and prox-mal migration of the humerus developed during theourse of rehabilitation despite anatomic fractureealing; this patient was considered to have a rotatoruff tear. One other patient was found to have anntraarticular loose body fragment with maintenancef fracture reduction and early short-term healing andnderwent arthroscopic fragment removal.

There were 6 shoulders that demonstrated humeralead subluxation at last radiographic follow-up (3osterior, 2 superior, and 1 posteroinferior), of which

were associated with other complications including

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J Shoulder Elbow Surg Smith et al 17Volume 16, Number 1

racture malreduction, fragment displacement, or tu-erosity resorption (Figure 2).

The 4 most common methods of osteosynthesisere then compared (Table I) relative to early com-lications (percutaneous fixation with terminally

Figure 1 Preoperative (A) and postoperative (B) anterof humeral head fragment.

igure 2 Venn diagram demonstrating relationship of complica-ions in patients with osteosynthesis.

hreaded wires or an intramedullary staple device, c

xed-angle blade plate or locking plate [Synthes,aoli, PA], intramedullary device with a tension band,r non–fixed-angle plate). Those with fixation with

ension-band wires and screws only (4 patients) andocked intramedullary nails (3 patients) were not in-luded for analysis because of the low number ofatients treated in this manner. Fixed-angle platesad a lower rate of malunion compared with other 3ost common methods of fixation (P � .01). Pairwiseomparisons among the 4 methods showed a signif-cantly lower rate for fixed-angle plates when com-ared with both non–fixed-angle plates (P � .01) andercutaneous devices (P � .01). However, there waso statistical difference in malunion when fixed-anglelating was compared with intramedullary fixationith a tension band (P � .05). Fixed-angle plates alsoad a significantly lower rate of malpositioning doc-mented on postoperative radiographs (P � .03).airwise comparisons among treatment groups alsoemonstrated that fixed-angle plates had decreasedracture malpositioning when compared with percu-aneous fixation (P � .01) and intramedullary fixationith a tension band (P � .03). However, there was no

tatistical difference when fixed-angle plating was

erior radiographs demonstrating incomplete reduction

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08). There was no significant difference in the ratesf fracture displacement, delayed healing, or hu-eral head subluxation between treatment groups

P � .05).There was no demonstrated difference (P � .05)

etween shoulder surgeons and nonshoulder sur-eons with respect to the rate of initial fracture mal-ositioning, fracture displacement, malunion, de-

ayed healing, or humeral head subluxation. Thereas also no difference in the rate of intraoperativealposition, fracture displacement, malunion, de-

ayed healing, or humeral head subluxation betweenracture types (P � .05) between surgeons.

eoperation in osteosynthesis group

Reoperation was performed in 21 patients (notncluding routine pin removal). Ten had removal ofmplanted hardware only at a mean of 6 monthsrange, 2 weeks to 30 months) because of looseningr a change in implant position, with all fractureschieving union at last follow-up. Three of the tenere in shoulders that had undergone percutaneousxation, five were in shoulders that had prominentubacromial hardware (via intramedullary devicesith tension bands), and two locking intramedullaryails were removed because of screw loosening orenetration of the articular surface.

Of the shoulders, 7 had revision internal fixation atmean of 3 months (range, 1 week to 8 months), ofhich 4 had revision for fracture displacement (1 withercutaneous pins, 2 with a fixed-angle plate, and 1ith a non–fixed-angle plate). In addition, 3 shoul-ers had revision fixation for delayed healing (2xed-angle plates and 1 non–fixed-angle plate), ofhich 1 fixed-angle plate was broken and had aositive culture at the nonunion site (Propionibacte-ium acnes).

One patient had reoperation for bone graftingnly after delayed healing at 9 months, eventuallyoing on to achieve union. One patient had a sal-age reoperation for conversion to hemiarthroplastyt 4 months postoperatively for humeral head col-

apse and tuberosity resorption. One patient had

able I Complications by type of osteosynthesis

Percutaneous(n � 17)

Intramedullarytension ban

alpositioning 5 4racture displacement 5 3alunion 6 3elayed healing 2 5umeral head subluxation 1 2urther surgery 4 4

eoperation with arthroscopy after 2 months for loose

ody excision. There was 1 acute deep infectionStaphylococcus epidermidis) treated at 3 weeks withsurgical debridements, intravenous antibiotics, and

etention of internal fixation with no recurrence ofnfection.

omplications in hemiarthroplasty group

Of the 22 shoulders requiring hemiarthroplastyTable II), 14 (64%) had an early complication, with 2atients requiring reoperation. Technical issuesevents related to fracture fixation or implant place-ent) were identified in 7 patients. Of these 7, 1 had

mplantation of an undersized humeral head compo-ent with obvious mismatch of the glenohumeral sur-aces resulting in posterosuperior subluxation and 6ad malreduction of the greater tuberosity (�1 cm)ith a median distance of 2 cm (range, 1.5-2.5 cm)istal to the humeral head component (Figure 3). Of

hese 6, 2 healed without further displacement andhad complications directly related to tuberosity

ealing, including resorption, nonunion, or dis-lacement. Of the 7 patients with technical issues,also had implantation of the stem into a valgus

osition (Figure 4) with the proximal lateral portionf the humeral implant abutting the proximal lateralumeral cortex.

Of the remaining shoulders that had acceptablemplant insertion and fracture reduction, 7 had com-lications directly related to tuberosity healing. Of

hese, 3 had tuberosity resorption after tuberosityisplacement or nonunion, 3 had tuberosity resorp-

ion and humeral head subluxation despite reason-ble fracture fragment alignment having been main-

ained, and 1 had displacement of both the lesser andreater tuberosities with resultant nonunion withoutvidence of significant resorption.

Humeral head subluxation was identified in a sub-roup of 7 shoulders (32%). Of these, 3 had superiorubluxation alone, 2 were anterosuperior, and 2ere posterior-superior. All 7 were a result of associ-ted complications (Figure 5) resulting from technical

ssues or tuberosity healing problems (resorption, dis-lacement, nonunion).

ice with18)

Non–fixed-angleplates (n � 18)

Fixed-angleplates (n � 22)

Pvalue

3 0 .035 2 .337 0 �.013 6 .591 2 �.997 4 .53

devd (n �

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J Shoulder Elbow Surg Smith et al 19Volume 16, Number 1

mplant malpositioning, nonunion, or humeral headubluxation between shoulder surgeons and non-houlder surgeons (P � .05).

eoperation in hemiarthroplasty group

Two patients underwent reoperation after hemiar-hroplasty for deep infection (one with Staphylococ-us epidermidis and the other with Staphylococcusureus and Propionibacterium acnes). Both were

reated with debridement, intravenous antibiotics,nd retention of the components. At last follow-up,oth were clinically free of infection.

racture classification

Of the 104 shoulders examined, 8 had inade-uate radiographs to classify the fracture adequatelybased on consensus review) and were excluded forhe purposes of comparison. In 66 (69%) of theemaining 96 shoulders, there was perfect agreement

able II Patients treated with shoulder hemiarthroplasty.

Case No. Age (y) SexTime to

surgery (d)Fracture

type (Neer) Imp

1 80 2 4 4

2 67 2 2 4

3 87 2 2 44 71 2 6 4

5 82 1 7 3

6 57 2 19 47 58 2 9 48 82 2 2 4

9 80 2 0 410 71 2 11 Head split11 47 2 3 3

12 83 2 2 413 79 1 4 414 81 2 1 415 68 1 4 316 70 1 14 417 61 1 3 318 75 2 6 419 29 2 17 420 44 1 0 421 60 2 1 422 51 2 21 4

The Implant types were as follows:1) Cofield humeral stem (Smith & Nephew),2) Aequalis standard humeral stem (Tournier), and3) Global humeral fracture stem (Depuy).

etween the operating surgeons and the consensus e

eviewers with regard to the number of fracture parts.f the remaining 30 shoulders, 26 (87%) wereraded as having fewer displaced fragments (or a

ower Neer classification) by consensus examinationf the authors and 4 (13%) were graded as havingewer displaced fragments by the operating sur-eons.

ISCUSSION

Nonoperative treatment of proximal humeral frac-ures is generally recommended for nondisplaced orinimally displaced fractures of the proximal hu-erus, with satisfactory results being expected.20 Op-rative intervention is usually recommended for thereatment of displaced fractures to prevent deformitynd improve function,27 but several authors haveuestioned whether operative intervention with anyracture type significantly improves functional out-omes (compared with nonoperative care) or further

* Complication

Tuberosity malreduction with nonunion and resorption, with stemplaced in valgus

Tuberosity malreduction with nonunion, resorption, and superiorsubluxation

Tuberosity malreduction with resorption and superior subluxationTuberosity malreduction with resorption and anterior-superior

subluxation, with stem placed in valgusUndersized humeral head component with posterior-superior

subluxationTuberosity malreduction with malunionTuberosity malreduction with malunionTuberosity nonunion and displacement with reoperation for deep

infectionTuberosity resorption after displacementTuberosity resorption after displacementTuberosity resorption after nonunion and displacement, with

reoperation for deep infectionTuberosity resorption with superior subluxationTuberosity resorption with posterior-superior subluxationTuberosity resorption with anterior-superior subluxation

lant

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ions and risks. Recently, Court-Brown et al12 prospec-ively examined 2-part fractures of the proximal hu-erus and concluded that surgical intervention didot affect outcome when compared with nonopera-ively treated fractures in older patients regardless ofhe amount of displacement. Others have reportedimilar findings for 3-part fractures21,43; however,onoperative treatment for 4-part fractures has gener-lly been recognized to lead to poor functional out-omes, with a high rate of avascular necro-is.11,21,26,27

Despite these clinical findings, studies have dem-nstrated that displaced or malunited fractures have airect impact on functional outcome, with residualisplacement leading to inferior results in patientsndergoing osteosynthesis.9,11,18 Furthermore, the re-ultant malunions and nonunions can be difficult toanage, with unpredictable and often unsatisfactory

unctional results.1,2,4,7,8,24

Intramedullary rod fixation with a tensionand13,25 and plate-and-screw fixation with fixed-ngle17,23 and non–fixed-angle plates15,39 have

igure 3 Postoperative anteroposterior radiograph after hemiar-hroplasty demonstrating inferior malreduction of greateruberosity.

een reported to be effective. More minimal forms of c

xation, including suture fixation19,31 and pin fixa-ion,33,41,42 have also yielded good results, with au-hors reporting low rates of fixation loosening andminimal changes” in fracture reduction.

Although osteosynthesis with anatomic fracture fix-tion has not been shown to correlate reliably withnal outcome in proximal humeral fractures,12,31 an-tomic reduction has been found to relate directly tonal outcome in other periarticular injuries, such ashe femoral neck or distal radius. This may be be-ause of the difficult nature of obtaining rigid fracturexation in the proximal humerus. Whereas most frac-ure fixation devices work well in younger patientsith adequate bone, current fixation devices do notdequately stabilize the often eggshell-like humeralead or resist the powerful deforming forces of theotator cuff muscles.

In this study, patients who underwent fixation withfixed-angle plate (blade plate or locking plate) via

n open deltopectoral approach had a significantlyower incidence of fracture malreduction and mal-nion. However, there was no difference in the rate ofracture displacement, delayed healing, or humeralead subluxation between treatment groups. The rea-ons for the high rate of fixation failure with resultantracture displacement are not clear; however, lack ofdequate fixation in osteoporotic bone appears to bekey component. Those with tuberosity displacementere likely a result of inadequate stabilization of theony tuberosity fragment, which is often comminuted.lthough most authors do note minor or partialhanges in fragment position after fixation, stability ofhe fracture fixation construct with respect to changesn fracture alignment over time has not been uniformlyeported or well defined.

This study also demonstrated the difficulty inchieving ideal anatomic fracture reduction. Twelveatients who had osteosynthesis and seven who hademiarthroplasty were identified as having incom-lete reductions. Although this may be because ofifficulties with soft bone or comminution, we believe

hat this is likely a result of inadequate use of intraop-rative radiographs or fluoroscopy. We now recom-end the routine use of intraoperative fluoroscopy toerify hardware placement and an anatomic stableeduction.

Boileau et al critically examined the factors that ledo functional outcome failures in patients who under-ent hemiarthroplasty and found a 27% incidence of

esser or greater tuberosity malpositioning at the in-ex operation, with a resultant 50% of patients withisplacement at final follow-up.8 Furthermore, final

uberosity position was shown to correlate directlyith functional outcome. Other authors have empha-

ized that tuberosity position and healing comprisehe most important factor predicting functional out-

ome after hemiarthroplasty.14,32,34,40

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J Shoulder Elbow Surg Smith et al 21Volume 16, Number 1

The results presented in this study support those ofoileau et al7,8 and Robinson et al,34 with high rates

Figure 4 A, Radiograph taken immediately postopeinferior malreduction of greater tuberosity. B, Radiograresorption and proximal humeral subluxation.

igure 5 Venn diagram demonstrating relationship of complica-ions in patients with hemiarthroplasty.

f tuberosity-related complications observed in this b

tudy. These tuberosity complications frequently led toccentric positioning of the humeral head relative tohe glenoid. Six of the seven patients with humeralead subluxation (of which six also had decreasedcromiohumeral distance) were related to initial tu-erosity malpositioning, resultant nonunion, or re-orption.

Boileau et al8 showed that correct positioning ofhe implant is essential to allow for anatomic tuberos-ty reconstruction. Although some investigators haveecommended lateralization of the tuberosities toaximize the length-tension relationship of the rotatoruff musculotendinous unit,14 we view this with cau-ion. Healing of the tuberosities is recognized to behe key factor in determining functional outcomes withemiarthroplasty.7,8,11

The concept of lateralization should be clarified tomphasize a more anatomic humeral head offset.umeral implants with a straight stem such as theofield 2 humeral prosthesis (Smith & Nephew), Ae-ualis standard humeral prosthesis (Tornier, Monte-

ly demonstrating humeral stem placed in valgus withken at 1 year postoperatively demonstrating tuberosity

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22 Smith et al J Shoulder Elbow SurgJanuary/February 2007

Depuy, Warsaw, IN) should not be placed in valgusdistal stem angulated medially relative to the humeralhaft). Although stem positioning in this manner mayive a false sense of lateralization, the length-tensionelationship of the rotator cuff to the humeral implants not enhanced and acts only to minimize shaft-uberosity contact. In this study, the 2 patients whoad straight humeral stems placed in valgus both haduberosity resorption and nonunion with proximal hu-eral migration. Therefore, we recommend straight-

tem placement in line with the humeral shaft (avoid-ng valgus), using the humeral head size to tension theotator cuff and tuberosity fragments correctly. Hu-eral prostheses that have a medial offset built into

he stem, such as with an apex lateral bend as ob-erved recently with the Aequalis fracture prosthesisTornier), should be placed in an appropriate positiono allow for anatomic reduction of the tuberosities tohe humeral shaft. This concept in fracture prosthesisesign continues to evolve.

This study did not demonstrate a difference in theate of complications between dedicated shoulderurgeons and nonshoulder surgeons with respect toracture malposition, fragment displacement, mal-nion, or delayed healing. Although this may haveeen a result of bias, with more complex fractureseing treated by the shoulder surgeons, these differ-nces could not be elicited in this study. Fracturelassification agreement between operating surgeonsnd the authors’ consensus was less than perfect, withperating surgeons consistently classifying fracturess more severe than the reviewers. Although this maye a result of findings not identifiable by radiographslone, we believe that this likely represents difficulties

n understanding fracture fragment position with con-emporary images.35

With these factors in mind, as well as informationleaned from this study, our approach to fracturexation has been modified to include the followingreatment principles:

● Correct identification and proper understandingof the fracture type are essential. These mayrequire additional radiographs or evaluationwith computed tomography with 3-dimensionalreconstructions.35 In fractures with borderlinedisplacement, nonoperative treatment should bestrongly considered.

● The fixation construct should be applied to allowcompression of the fracture fragments. The useof fixed-angle devices may decrease the fre-quency of fragment malpositioning and resultantmalunion.

● Fixation constructs (intramedullary device orplates and screws) should be augmented, asnecessary, with heavy sutures passing adjacent

to bony fragments through rotator cuff tissue and fi

back to the fixation implant to provide maximumimplant-fragment stability.

● The greater tuberosity fixation height should re-late well to the height of the upper lateral aspectof the head fragment or humeral head prosthe-sis. Intraoperative fluoroscopy is recommendedto confirm final fracture fragment positioning.

● When inserting a proximal humeral prosthesis,the proximal aspect of the implant should benarrow enough to allow ample space for bonecontact to encourage healing. Humeral implantswith large metaphyseal dimensions make ana-tomic reduction difficult and leave minimalspace for bone grafting.

● Humeral implants with a straight stem should notbe placed in valgus, thus compromising thearea of bone contact for tuberosity-shaft heal-ing. Humeral stems that have a medial offset inthe stem with an apex lateral bend should beplaced in an appropriate position to allow foranatomic reduction of the tuberosities to thehumeral shaft.

● Although the best position for immobilization isnot known, we now routinely place the shoulderin an abduction pillow to reduce the strain fromthe rotator cuff on the repaired fracture frag-ments.

● From the results noted in this study (high rate offracture displacement despite anatomic fracturereduction), the length of immobilization hasbeen increased to allow for early healing tooccur before mobilization.

Limitations in this study are directly related to thenherent problems of retrospective patient review.o comparison group was included for evaluation,nd no protocol for directing care was used. Mul-

iple surgeons were involved in treatment. Caseomplexity bias was accounted for by limiting theases examined to patients residing in the immedi-te regional service area. However, the large ter-

iary referral practice of this institution may haveed to a more complex patient population withultiple injuries and comorbidities falsely elevating

he complication rates. The length of follow-up wasariable in this study. Longer follow-up would likelyave yielded further insight into the late-occurringroblems that may have arisen as a result of theomplications encountered during the early phasesf care. Outcome measures for functional assess-ent were not assessed in this study; therefore, the

ate of early complications was not correlated withunctional outcome variables.

In conclusion, the rate of complications in this studyas high and was not related to fracture type, type ofxation, or surgeon expertise. Although these resultsre directly a factor of how complications were de-

ned, the high rate of malunion, nonunion, and reop-

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J Shoulder Elbow Surg Smith et al 23Volume 16, Number 1

ration for patients undergoing osteosynthesis cannote overstated. We also believe that the rates ofracture displacement and resultant fracture malunionay have previously been underreported and may be

he contributing factor for the often disappointingesults with proximal humeral fracture operative treat-ent. Despite the recent advances in arthroplasty

echniques,16 tuberosity-related complications con-inue to be a significant problem. Tuberosity stabilitynd anatomic healing should remain the primaryoal to which all intraoperative measures are di-ected. To maximize functional outcomes, continueddvances will be necessary to maximize fracture frag-ent fixation and healing. 3,28

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